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Dental Patient Registration Form
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Name: |
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Birth Date: |
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Home Phone: |
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Street Address: |
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City: |
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State: |
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Zip: |
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Mobile Phone: |
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Email: |
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Employer/School: |
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Employer Phone: |
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Employer Address: |
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City: |
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State: |
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Zip: |
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Spouse/Partner/Parent's Name: |
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Employer: |
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Employer Phone: |
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Whom may we thank for referring you? |
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Person to contact in case of emergency: |
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Phone: |
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Responsible Party
Is
Responsible Party details same as Patient details? |
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Responsible Party Account Name: |
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Relation to Patient: |
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Street Address: |
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City: |
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State: |
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Zip: |
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Driver's License#: |
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Birth Date: |
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Employer: |
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Work Phone: |
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Currently a Patient in our office: |
Yes
No *
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Email: |
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Mobile Phone: |
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Additional Insurance |
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Name Of Insured: |
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Relation to Patient: |
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Birth Date: |
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Social Security#: |
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Date Employed: |
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Employer: |
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Employer Phone: |
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Employer Address: |
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City: |
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State: |
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Zip: |
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Insurance Company: |
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Group#: |
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Union Local#: |
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Insurance Address: |
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City: |
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State: |
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Zip: |
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How much is your deductible? |
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How much have you used? |
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Max. Annual Benefit: |
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Dental History |
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Reason for today's visit: |
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Date of last dental care: |
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Former Dentist: |
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Date of last dental x-rays: |
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Dentist Address: |
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City: |
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State: |
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Zip: |
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How often you floss? |
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How often you brush? |
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Medical History |
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Physician's Name: |
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Date of last visit: |
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Have you ever taken any of the group of drugs collectively referred to as "fen-phen"?
These include combinations of Ionimin, Adipex, Fastin (brand names of pentermine),
Pondimin (fenfluramine) and Redux (dexfenfluramine).
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Have you had any serious illness or operations?
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If yes, describe: |
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Have you ever had a blood transfusion? |
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If yes, give approximate date: |
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(Women) Are you pregnant?
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Nursing?
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Taking birth control pills? |
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Please list medications you are currently taking and the correlating diagnosis: |
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Allergies: |
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Authorization and Release
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To the best of my knowledge, the above information is complete and correct. I understand
that it is my responsibility to inform my Doctor if I, or my minor child, ever have
a change in health. |
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I certify that, I and/or dependent(s) have Insurance coverage with
(Insurance
Company) and assign directly to insurance benefits,if any, otherwise payable to
me for services rendered.I understand that I am financially responsible for all
charges whether or not they are paid by insurance. I authorize the use of my signature
on all insurance submissions. |
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The above named dentist may use my health care information and may disclose such
information to the Insurance Company(ies) and their agents for the purpose of obtaining
payment for services and determining insurance benefits or the benefits payable
for related services This consent will end when the current treatment plan is completed
or one year from the date signed below. |
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Name of Patient, Guardian, or Personal Representative: |
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PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED. |
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